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Star Stroke
What is stroke?
Definition
?
A stroke occurs when there is (1) ischemia (inadequate blood flow) to a part of the brain or (2) hemorrhage into the brain that results in the death of brain cells.
Statistics
Stats
- 30% Hemorrhagic
- 70% Ischemic
- Philippines: 2nd leading cause of death
2 Types
An ischemic stroke results from inadequate bloodflow to the brain from partial or complete occlusion of an artery.
Types
Hemorrhagic strokes result from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage)
Embolic
Ischemic Subtype
Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel
Intracerebral Hemorrhage
bleeding within the brain caused by a rupture of a vessel
Subarachnoid Hemorrhage
Hemorrhagic Subtype
occurs when there is intracranial bleeding into the cerebrospinal fluid– filled space between the arachnoid and pia mater membranes on the surface of the brain
Risk Factors
!
Pathophysiology
Modifiable
- hypertension
- heart disease
- diabetes mellitus
- smoking
- excessive alcohol consumption
- obesity
- sleep apnea
- metabolic syndrome
- lack of physical exercise
- poor diet
- drug abuse.
NonModifiable
- age
- gender
- ethnicity or race
- family history or heredity.
Small Artery Occlusion
Large Artery Atherosclerosis
Cardio-aortic Embolism
Decreased CBF
Decreased O2 and Glucose Infarct
Increased Anaerobic Metabolism
Decreased ATP
Increased lactate
Ischemic
Astrocyte death
Dysfunction of Na/K ATPase pump on neurons
Astrocytes release glutamate
Increase Na, Ca, decrease K
H2O influx with Na
Microglia clear debris
Edema
Excitotoxicity
Depolarization
Inflammation
Compress Vessels and tissues
Activate mGlur
Neurons release Glu
Ca Influx
Secondary Inflammation
Activate Catabolic proteases, lipases, nucleases and oxidative injury
Aneurysm
Amyloid Angiopathy
Hypertension
Drugs
Blood vessel ruptures and bleeds, increased ICF
Blood cytotoxicity and sudden focal internal brain trauma from hematoma
Decreased ATP
RBC Lysis
Increased lactate
Astrocyte death
Dysfunction of Na/K ATPase pump on neurons
Cytotoxic hb release
Astrocytes release glutamate
Increase Na, Ca, decrease K
H2O influx with Na
Hemorrhagic
Microglia clear debris
Depolarization
Free Radical generation
Edema
Excitotoxicity
Inflammation
Neurons release Glu
Activate mGlur
Compress Vessels and tissues
Oxidative damage
Ca Influx
Secondary Inflammation
Activate Catabolic proteases, lipases, nucleases and oxidative injury
Necrosis
Manifestations
- Paralyzed right side: hemiplegia
- Impaired speech/language aphasias
- Impaired right/left discrimination
- Slow performance, cautious
- Aware of deficits: depression, anxiety
- Impaired comprehension related to language, math
- Paralyzed left side: hemiplegia
- Left-sided neglect
- Spatial-perceptual deficits
- Tends to deny or minimize problems
- Rapid performance, short attention span
- Impulsive, safety problems • Impaired judgment
- Impaired time concepts
The Experiment
experiment
Analyze your Results
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results
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acute management
Management
• Ensure patent airway.
• Call stroke code or stroke team.
• Remove dentures.
• Perform pulse oximetry.
• Maintain adequate oxygenation (SaO2 >95%) with supplemental O2, if necessary.
• Establish IV access with normal saline.
• Maintain BP according to guidelines (e.g., Cardiac Life Support).*
• Remove clothing.
• Obtain CT scan or MRI immediately.
• Perform baseline laboratory tests (including blood glucose) immediately, and treat if
hypoglycemic.
• Position head in midline.
• Elevate head of bed 30 degrees if no symptoms of shock or injury. • Institute seizure precautions.
• Anticipate thrombolytic therapy for ischemic stroke.
• Keep patient NPO until swallow reflex evaluated.
Ischemic
- Recombinant tPA via IV within 3-4.5 hours
- Aspirin
- Warfarin
- MERCI
Ischemic
Hemorrhagic
- Management of hypertension
- Immediate evacuation of aneurysm
- Surgical resection or radiosurgery
- Surgical decompression
- Clipping or coiling of aneurysm